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Oral Presentation

Middle cerebral artery thrombectomy plus carotid stenting or postponed carotid endarterectomy: which is the best approach in acute stroke treatment?

Author(s):

Ana Luísa Rocha, Pedro Abreu, Pedro Castro, and Elsa Azevedo

Abstract:

Introduction: While performing endovascular techniques for middle cerebral artery (MCA) recanalization in hyperacute stroke, there is some controversy regarding immediate stenting of a concomitant carotid stenosis, or postponing for endarterectomy in a more stable clinical condition within the first 2 weeks since symptom onset. Aiming to raise discussion around this issue, we present two acute stroke clinical cases where both attitudes could be considered.
Case Reports: Case 1: 57-year-old male, previously anticoagulated (rivaroxaban 20mg) for deep venous thrombosis, presented right MCA occlusion symptoms, scoring 15 on NIHSS. Angio-CT scan showed right ICA stenosis, and a thrombus in the right MCA M1 segment. Due to anticoagulation, the patient was immediately selected for thrombectomy (Thrombolysis in Cerebral Infarction (TICI) 2b), with an end-of-procedure NIHSS of 8. Duplex ultrasound confirmed a 75% ICA atherosclerotic stenosis. The patient was discharged to his reference hospital with indication for endarterectomy, scoring 3 on NIHSS. Case 2: 59-year-old female presented with left MCA occlusion symptoms, scoring 12 on NIHSS. Angio-CT showed occlusion of left ICA and MCA (M1 segment). We performed thrombolysis followed by MCA thrombectomy (TICI 3), with an end-of-procedure NIHSS score of 19; angiography showed a sub-obliterative ICA stenosis (>90%) at the end of the procedure (occlusion opened by the thrombectomy catheter passing through?), also observed in a duplex ultrasound exam. NIHSS subsequently improved to 4, and a successful endarterectomy was performed 7 days after admission.

Conclusion: Although we decided to postpone carotid stenosis treatment, using later endarterectomy instead of immediate endovascular treatment during the thrombectomy procedure, doubts were raised regarding the best approach. We suggest a systematic register of these cases in a multicentre study, to gather more information that might lead to supported decisions, as there are no current specific guidelines addressing this issue.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.